Equity and universality are implicit in universal health coverage (UHC), although ambiguity has led to differing interpretations and policy emphases that limit their achievement. Diverse country experiences indicate a policy focus on differences in service availability and costs of care, and neoliberal policies that have focused UHC on segmented financing and disease-focused benefit packages, ignoring evidence on financing, service, rights-based and social features that enable equity, continuity of care and improved population health. Public policies that do not confront these neoliberal pressures limit equity-promoting features in UHC. In raising the impetus for UHC and widening public awareness of the need for public health systems, COVID-19 presents an opportunity for challenging market driven approaches to UHC, but also a need to make clear the features that are essential for ensuring equity in the progression towards universal health systems.
Equity in Health
The new Global AIDS Strategy (2021–2026) uses an inequalities lens to identify, reduce and end inequalities that represent barriers to people living with and affected by HIV, countries and communities from ending AIDS. The Strategy outlines a comprehensive framework for transformative actions to confront these inequalities and to respect, protect human rights in the HIV response. It puts people at the centre to ensure that they benefit from optimal standards in service planning and delivery, to remove social and structural barriers that prevent people from accessing HIV services, to empower communities to lead the way, to strengthen and adapt systems so they work for the people who are most acutely affected by inequalities, and to fully mobilize the resources needed to end AIDS.
This paper explores the features and drivers of frameworks for healthy societies that had wide or sustained policy influence post-1978, globally and in selected southern regions, in India, Latin America and East and Southern Africa. The authors implemented a thematic analysis of 150 online documents and reviewed the findings with expertise from the regions covered. Globally, comprehensive primary healthcare, whole-of-government and rights-based approaches have focused on social determinants and social agency to improve health as a basis for development. Biomedical, selective and disease-focused technology-driven approaches have, however, generally dominated, positioning health improvements as subsequent to macroeconomic growth. Historical approaches in the three southern regions that integrated reciprocity and harmony with nature were suppressed by biomedical models during colonialism and by postcolonial neoliberal economic reforms. With widening differences between biosecurity approaches on the one hand and holistic, ecological approaches on the other, economic, the context in the 2000s of ecological, pandemic crises and social inequality is argued to imply that which ideas dominate will be critical for health futures. The authors point to what this implies for building approaches to healthy societies, including for a more equitable circulation of ideas between regions in framing global ideas.
The authors measured the fatalities from Covid-19 in Lusaka. PCR tests were done post mortem on 372 deceased people of all ages at the University Teaching Hospital morgue in Lusaka, Zambia, enrolled within 48 hours of death between June and September 2020; PCR results were available for 364 (97.8%). SARS-CoV-2 was detected in 58/364 (15.9%). Most deaths in people positive for covid-19 (51/70; 73%) occurred in the community and none had been tested for Covid-19 before death. Among the 19/70 people who died in hospital, six were tested before death, while for the 52/70 people with data on Covid-19 related symptoms, only five were tested before death. Covid-19 was identified in seven children, only one of whom had been tested before death. While the proportion of deaths with covid-19 increased with age, 76% were aged under 60 years. The authors conclude that deaths with covid-19 were more common in Lusaka than indicated in official reports, with most occurring in the community, where testing capacity is lacking, but also due to lower levels of testing in facilities and in those presenting with typical symptoms of covid-19.
This online study assessed the prevalence of mental health symptoms as well as emotional reactions among 2005 respondents aged 18 years and older in seven African countries between 17 April and 17 May 2020 corresponding to the lockdown period in these countries. Respondents self-reported feeling anxious, worried, angry, bored and frustrated. Multivariate analysis revealed that males, those aged >28 years, those who lived in Central and Southern Africa, those who were not married, the unemployed, those living with more than six persons in a household, had higher odds of mental health and emotional symptoms. Health care workers were less likely to report feeling angry than other types of workers.
This report highlights the ways that the coronavirus pandemic has the potential to lead to an increase in inequality in almost every country at once, the first time this has happened since records began. The virus has exposed, fed off and increased existing inequalities of wealth, gender and race. Over two million people have died, and hundreds of millions of people are being forced into poverty while many of the richest – individuals and corporations – are thriving. Billionaire fortunes returned to their pre-pandemic highs in just nine months, while recovery for the world’s poorest people could take over a decade. While the pandemic has exposed a collective frailty and the inability of a deeply unequal economy to work for all, it has also shown the vital importance of government action to protect health and livelihoods. Transformative policies that seemed unthinkable before the crisis have suddenly been shown to be possible.
Governments are incentivized to develop and implement health action programs focused on equity to ensure progress with effective strategies or interventions. This study identified strategies that facilitate the reduction of health inequalities. A systematic search strategy identified 4095 articles, of which 97 were included in the synthesis. Most of the studies included focused on the general population, vulnerable populations and minority populations. The subjects of general health and healthy lifestyles were the most commonly addressed. According to the classification of the type of intervention, the domain covered most was the delivery arrangements, followed by the domain of implementation strategies. The most frequent group of outcomes was the reported outcome in (clinical) patients, followed by social outcomes. The authors note that the strategies that facilitate the reduction of health inequalities must be intersectoral and multidisciplinary in nature, including all sectors with the health system.
This study examined social determinants of tobacco use in the Democratic Republic of the Congo (DRC), including region, sex, ethnicity, education, literacy, wealth index and place of residence, to gain insights on tobacco use among sub-national groups. The project analysed data from the DRC 2013–2014 Demographics and Health Survey. Tobacco use was found to be highest among working poor people, those with less education and low literacy. Older age people and those living in larger cities were more likely to smoke , although the relationship between age and smoking was not linear. Wealth was strongly related to smoking as was being engaged in services, skilled and unskilled manual labour and the army. Being in a professional, technical or managerial position was highly protective against smoking. The authors observe that the data indicate that tobacco use in the DRC, as is common in low income countries, is heavily concentrated in working poor people with lower educational status. Higher educational status is consistently predictive of avoiding tobacco use. They argue that examining only national-level data to ascertain tobacco use levels and patterns may lead to mistaken conclusions and inefficient and ineffective allocation of resources for control of tobacco use.
The 11th Bulletin of the SADC Response to COVID-19 in English, French and Portuguese provides an overview of the global, continental and regional situation as well as the measures that have been put in place with the support of WHO. It reports that the COVID-19 situation continues to rise in some states in the region, destabilizing the economies and other systems, and leading to a precarious food and nutrition situation. The report provides the short, medium and long term interventions that countries can put in place to address the situation in relation to issues such as food security, transport, health and economic recovery. Transport and trade facilitation is noted to remain a major challenge while noting achievements in this, including the Tripartite Guidelines on Trade and Transport Facilitation for Safe, Efficient and Cost Effective Movement of Goods and Services during the COVID-19 Pandemic which harmonise the guidelines of SADC, East African Community (EAC) and the Common Market for Eastern and Southern Africa (COMESA).
The East Central and Southern Africa Health Community has continued to monitor the status of COVID-19 in Burundi, Eswatini, Kenya, Lesotho, Malawi, Mozambique, Mauritius, Rwanda, South Sudan, Tanzania, Uganda, Zambia and Zimbabwe and to support countries mitigate effects of COVID-19. Due to the prevailing restrictions of travel, much has been provided through online discussions and support. The report indicates that the number of reported confirmed cases of COVID-19 and cases under care in the region is increasing, in spite of the context of under-reporting. The authors note that governments wish to open up economies to take care of individual and national economic survival and call for targeted and population interventions for modified social distancing mechanisms and for support for diagnostics, care of recovering cases, contact tracing and surveillance across countries, taking note of the fluid movement of people across borders. Adopting regional collaborative efforts is argued to be cost-efficient.